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6 <br />•OCT 2 6 2007SWRCB January 2006 <br />Spill Bucket Testing Report Form <br />This ftied for use by contractors performing annual testing of UST spill containment structures The completed form and <br />0 <br />printout3'from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: VALERO Date of Testing: 7-31-07 <br />Facility Address: 1612 W Hammer Ln <br />Facility Contact: Linh Phone: 952-2903 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): Mr. Yang <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: HMC -Henderson Maim. Co <br />Technician Conducting Test: Gavin Williams <br />Credentials': ❑ CSLB Contractor [X] ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: ❑ Hydrostatic ❑ Vacuum [X] Other <br />Test Equipment Used: I Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />Bucket Installation Type: <br />1. T-187 <br />[x] Direct Bury <br />❑ Contained in Sump <br />2. T-2 91 3 T-3 Diesel <br />[x] Direct Bury [x] Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump <br />4 <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />13 <br />13 13 <br />Bucket Depth: <br />12 <br />12 12 <br />Wait time between applying <br />vacuum/water and start of test: <br />1 hr <br />1 hr lhr <br />Test Start Time (T): <br />1:00 <br />1:00 1:00 <br />Initial Reading (RI): <br />11 <br />11 11 <br />Test End Time (TF): <br />2:00 <br />2:00 2:00 <br />Final Reading (RF): <br />11 <br />11 11 <br />Test Duration (TF — TI): <br />1 hr <br />1 hr 1 hr <br />Change in Reading (RF - RI): <br />None <br />None none <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />[X] Pass ❑ Fail <br />[X] Pass ❑ Fail [X] Pass ❑ Fail <br />❑ Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature:_ L411-1 Date: T-31 `0 <br />C <br />' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />mn- 1 a —n otr;—f <br />